Experiential Activity
I read the book “How We Do Harm: A Doctor Breaks Ranks About Being
Sick in America” by Otis Webb Brawley with Paul Goldberg. I chose this book
because it brings to light the multiple ethical issues that can be encountered in
the medical profession particularly oncology. With my pharmacy background,
this book made me really consider the various ethical issues faced by various
health professionals. No one is immune to it and it is important to be aware of
because these issues can have negative impacts on patient’s lives.
This book was written by an oncology doctor that worked for Atlanta’s
Grady Hospital. This hospital accepted patients that were underinsured or
uninsured and have financial difficulties. The hospital doctors practice in a
setting where they are reviewed by their colleagues and are not driven by profit
and do not have quotas to meet to bring in a certain amount of revenue. This
information helped me to understand the differences in ways that some people
will practice medicine. Dr. Brawley shares stories of various patients and their
struggles through cancer. The opening chapter is heartbreaking and is just the
beginning of many examples of the American Health System and the ways that it
is failing many people whether they are fully insured or not and whether they are
able to pay for medical care or not. I am going to pick just a few examples of the
ethical issues that stuck out to me. These issues have made me stop and think
about my own career in the health field and how I want to care for patients. It
also made me think of how I will handle my own health care as well as my family
in order to help prevent more people from suffering due to decisions being made,
in terms of treatment options for the wrong reasons.
Overall I felt that this book portrayed oncology doctors that were in private
practice in a negative way. It did not portray all oncology doctors in a negative
light but certain ones especially those in private practice. He points out that
when doctors practice in a setting, such as the one he does, where they are
reviewed by their colleagues that better decisions in terms of patient care are
made. The author brings up the fact that many doctors are also in business and
therefore driven by profits. This profit driven form of health care can have
negative impacts on patients in many ways regardless of their financial and
medical insurance status. This book brought to light some of the ways that
profits may influence how your doctor decides what treatment course to use.
The specific term that was used was “wallet biopsy.” Many doctors in private
practice made sure that you had good health insurance that would cover the
treatments and that you had the money to pay for the co-payments that were
required by the treatment. Some of the doctors referred patients to other
hospitals after the “wallet biopsy” came back negative. However on the other
hand if someone had very good insurance, then multiple tests and treatments
were provided that may not have been necessary but to the provider it was a
source of revenue.
One ethical dilemma that is faced on the usage of Procrit (a hormone used
to produce hemoglobin) to treat cancer fatigue. This was the first medication of
its kind and therefore was passed through the FDA quickly. Many doctors were
jumping on board and using this medication to treat cancer-fatigue. There were
profit benefits associated with the large use of this medication for cancer-fatigue
and many offices began asking cancer patients receiving cancer treatment if they
felt fatigued. If the answer was yes, they received this drug. The issue is that
the FDA did not provide Procrit with an approved indication of cancer-fatigue.
Also what exactly is “cancer-fatigue.” In addition were the nurses asking patients
if they felt tired prompting patients to say yes. This widespread use of this drug
ended up leading to stimulation in tumor growth. The patient’s story told in this
book was negatively impacted by this new drug. Her tumor grew and most likely
shortened her life. When she met Dr.Brawley, he explained to her the reasons
why he had chosen not to use this medication for cancer-fatigue. The studies
that were done did not include treatment of cancer-fatigue or involve treatment of
anemia in cancer. Dr. Brawley took the time to review the studies before
deciding to use a medication in his patients. He was not enticed by the added
revenue or kick backs offered by the drug company. Unfortunately many doctors
were and their patients suffered due to this. They were treating numbers and not
patients which resulted in extra costs and harm to many patients. I would like to
think that if I were a medical practitioner at that time, I would have taken the time
to review the studies before opting to widely use a new medication in my
patients. I would hope that I would not jump on the band wagon and be enticed
by money instead of focusing on the care of my patients. Dr. Brawley took the
time to educate the patient (Lilla) in this book. Once she was educated on the
medication and the potential harms she decided to testify with other patients
about the medication. Eventually the medications were restricted for appropriate
use by the FDA.
Another ethical dilemma that is touched on in the book is the screening of
prostate cancer. This book tells a story of a patient that was in good health and
just happened to have a prostate cancer screening done. Turns out the
screening tool that was used (PSA level) may not accurately predict cancer. It
also turns out that prostate cancer is very slow growing and a majority of the
time, something else will cause the patient to die instead of the cancer. Ralph,
the patient in the book was aggressively treated at 70 years old for prostate
cancer due to an elevated PSA level. Ralph ends up with impotence and
incontinence. His quality of life severely declines. This all happened because of
a scare due to elevated PSA levels that continued after his initial treatment. The
information originally given to him at the health screening caused him to be
overly concerned and to want extra treatment (radiation and surgery) to “cure” his
cancer. This was costly and decreased his quality of life. I would hope that I
would be able to effectively educate my patients and give them all of the facts in
order to calm their nerves. Ralph was 70 and most likely would have lived a
good quality of life without ever knowing of the slow growing prostate cancer. He
would have most likely died of other causes, but would have been able to
maintain his quality of life. I think that the local hospital offering this “free”
prostate screening used this as a tool to gain more business and revenue. They
created a fear in patients and a sense of urgency that they required extensive
treatment to cure their cancer. I would want to review all of the information
available, including the trial showing that PSA did not accurately detect cancer
that required treatment. Dr. Brawley speaks with Ralph about these studies,
unfortunately it is too late for Ralph as his quality of life has been and will
continue to be negatively impacted due to unnecessary treatment.
Another ethical dilemma presented was an oncologist that specialized in
breast cancer, decided to take on a colon cancer case. This was out of his
normal scope of practice and is unknown as to exactly why he decided to take
this case on. It is eluted to that it was possibly for extra revenue or
acknowledgement. Unfortunately for Martin this was not good. Dr. Wilson was
unaware of current practice guidelines on the best treatment of advanced colon
cancer and was not effectively treating Martin. The fact that Martin had a “wallet
biopsy” and was not going to be able to afford his expensive co-pays for this
treatment, he was referred to Grady hospital for people that were underinsured or
unable to afford their medical treatment. This most likely saved Martin’s life
because his case was reviewed by oncologists that specialized in colon cancer
and also utilized their peers to double check treatment decisions. The fact that a
doctor would take on an advanced cancer case was unethical. I would hope that
as a practitioner if I was unable to effectively manage a patient, I would recognize
the need to refer the patient appropriately and not guess at treatment to increase
my own revenues. I also think that it would have been appropriate to ask Dr.
Wilson why he took on a case that he was not familiar with or asking why he
chose the treatment plan that he did. Maybe bringing attention to it would
change Dr. Wilson’s future practice and prevent him from taking on cases that he
is not best suited for.
Throughout this book other ethical dilemmas are discussed such as a
clinical trial performed without the appropriate approval and giving patients
excessive doses of medication that caused harmful side effects. Unfortunately
due to the vested interest in the person holding the trial, the initial side effects
that presented were an indication to stop or decrease the medication and could
have prevented permanent damage. However this was not done. Throughout
the book, a majority of the ethical issues revolved around the revenue that the
decision would bring in instead of the treatment and care of the patient.
This book made me stop and think about the way the health system works
in the United States. I do not think that all doctors are bad or make choices
based on the wrong reasons but I do think that it happens more frequently than I
would have thought. In reality health care is a business and business need to
profit in order to be sustainable. Incentives to gain extra profit by drug
companies can lead people into making bad decisions that normally they
wouldn’t have. I understand more why it is necessary to not allow drug
companies to woo doctor’s offices. It is too easy to sway people in the wrong
direction, even if you think as health professionals that their judgment would be
better than that. In reality everyone is humans. Everyone is driven by different
things and unfortunately money drives a lot of people. We need money to pay
for our homes, large school loans, and to provide for our families. It is sad to
think that these educated professionals made rash decisions, especially about
Procrit and Aranesp before all the information was available as to what these
medications might do. I would hope that as a practitioner I would take the time to
evaluate and make my own logically decision instead of jumping on a band
wagon.